A nurse is caring for a 6-week-old infant.
Specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Correct Answers:
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A) Checking clothing for loose buttons is important because toddlers can easily remove and swallow small objects, which can lead to choking hazards.
- B) Adjusting the water heater temperature to 54° C (129.2° F) is not recommended as it poses a risk of scalding. Safe water temperatures for households with toddlers should be at or below 49° C (120° F).
- C) Placing screens on all windows is a crucial safety measure to prevent toddlers from falling out of open windows, which can lead to serious injuries or fatalities.
- D) Providing balloons for play is not advisable as uninflated or broken balloons can be a choking hazard for toddlers. It is one of the leading causes of choking deaths in children.
Correct Answer is B
Explanation
Rationale:
A. Retesting in a week may be necessary, but notifying the public health department is a more immediate concern.
B. Notifying the public health department is essential for contact tracing and preventing the spread of syphilis.
C. Involving the patient's parents may not be appropriate for a 20-year-old patient.
D. Metronidazole is not typically used to treat syphilis; penicillin or other antibiotics are the standard treatment.
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